Medicare 101: The A,B,C, and D\’s of Medicare


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A overview of the basic components of Medicare, how they work, and what financial exposure exists under Basic Medicare coverage. Highlights supplemental or alternative coverage options within the Medicare framework.

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Medicare 101: The A,B,C, and D\’s of Medicare

  1. 1. Mark Lane A B C and D’s of Medicare
  2. 2. <ul><li>GarityAdvantage Agencies </li></ul><ul><ul><li>National FMO </li></ul></ul><ul><ul><li>Focused on the Senior Market </li></ul></ul><ul><ul><ul><li>Medicare Advantage </li></ul></ul></ul><ul><ul><ul><li>Medicare Supplement </li></ul></ul></ul><ul><ul><ul><li>Group Retiree Medical </li></ul></ul></ul><ul><ul><ul><li>PDP </li></ul></ul></ul><ul><ul><ul><li>Hospital Indemnity </li></ul></ul></ul><ul><ul><ul><li>Dental </li></ul></ul></ul><ul><ul><ul><li>Final Expense </li></ul></ul></ul><ul><ul><ul><li>Funeral Trust </li></ul></ul></ul><ul><ul><ul><li>Life </li></ul></ul></ul>
  3. 3. <ul><li>GarityAdvantage Agencies offers </li></ul><ul><ul><li>Competitive Nationally recognized products </li></ul></ul><ul><ul><li>Comprehensive Training </li></ul></ul><ul><ul><li>Market Expertise </li></ul></ul><ul><ul><li>Ask us about our Lead Programs for Medicare Products! </li></ul></ul><ul><ul><li> </li></ul></ul><ul><ul><li>800-234-9488 </li></ul></ul>
  4. 5. <ul><li>Medicare Background </li></ul><ul><li>Original Medicare – Parts A & B </li></ul><ul><li>Medicare Part C – Options to Original Medicare </li></ul><ul><li>Medicare Supplements </li></ul><ul><li>Medicare Part D </li></ul><ul><li>Coverage Options </li></ul><ul><li>Questions??? </li></ul>
  5. 6. What is Medicare? A health insurance program for people: age 65 or older under 65 with certain disabilities any age with End Stage Renal Disease Administered by the Federal Government through the Centers for Medicare & Medicaid Services (CMS) Medicare currently provides coverage for 45-46 million People 77 million people aging into Medicare over the next 20 years
  6. 7. <ul><li>Covers: </li></ul><ul><ul><li>Inpatient Hospital </li></ul></ul><ul><ul><ul><li>$0 co-pay for days 1-60 after the deductible has been met </li></ul></ul></ul><ul><ul><ul><li>$283 co-pay for days 61-90 </li></ul></ul></ul><ul><ul><ul><li>$566 co-pay for days 91-150 (Lifetime Reserve Days) </li></ul></ul></ul><ul><ul><li>Home Healthcare </li></ul></ul><ul><ul><ul><li>Medically necessary care ordered by a doctor and provided by a Medicare-certified home health agency (VNA) </li></ul></ul></ul><ul><ul><li>Hospice Care </li></ul></ul><ul><ul><ul><li>Terminally ill with life expectancy of less than 6 months </li></ul></ul></ul><ul><ul><ul><li>Home or Medicare approved facility </li></ul></ul></ul><ul><ul><li>Skilled Nursing Facility up to 100 days </li></ul></ul><ul><ul><ul><li>Only after a 3 day hospital stay </li></ul></ul></ul><ul><ul><ul><li>Co-pays for days 21-100 are $141.50 per day </li></ul></ul></ul>
  7. 8. <ul><li>The deductible for Part A is $1,132 in 2011 </li></ul><ul><li>Benefit period </li></ul><ul><ul><li>Starts the day you go into a hospital </li></ul></ul><ul><ul><li>Ends when you go 60 days without hospital or skilled nursing care </li></ul></ul><ul><ul><li>NO LIMIT </li></ul></ul><ul><li>No premium for those with 40 quarters of work </li></ul><ul><ul><li>$ 248 per month for those with more than 30 quarters </li></ul></ul><ul><ul><li>$ 450 per month for those with less than 30 quarters </li></ul></ul>
  8. 9. <ul><li>Covers: </li></ul><ul><ul><li>Doctors Services </li></ul></ul><ul><ul><li>Emergency Room Services </li></ul></ul><ul><ul><li>Outpatient care </li></ul></ul><ul><ul><ul><li>In hospital or ambulatory surgical center if not admitted </li></ul></ul></ul><ul><ul><li>Laboratory Tests </li></ul></ul><ul><ul><ul><li>Certain blood tests (diabetes screening for those with risk factors) </li></ul></ul></ul><ul><ul><ul><li>Urinalysis </li></ul></ul></ul><ul><ul><li>Some Diagnostic Screenings </li></ul></ul><ul><ul><ul><li>Bone Density Screenings </li></ul></ul></ul><ul><ul><ul><li>Cardiovascular Screenings </li></ul></ul></ul><ul><ul><ul><li>Colorectal Cancer Screenings </li></ul></ul></ul><ul><ul><ul><li>X-rays, MRI’s, CT scans, EKG’s </li></ul></ul></ul>
  9. 10. <ul><ul><li>Certain Drugs not covered under Part D </li></ul></ul><ul><ul><ul><li>Oral cancer drugs, some types of injected drugs </li></ul></ul></ul><ul><ul><li>Durable Medical Equipment </li></ul></ul><ul><ul><ul><li>Oxygen equipment, Wheelchairs, Walkers, etc… </li></ul></ul></ul><ul><ul><li>Flu Shots, Hep B shots </li></ul></ul><ul><ul><li>Mammograms and Pap tests </li></ul></ul><ul><ul><ul><li>Once every 12 months </li></ul></ul></ul><ul><ul><li>Mental Health Care </li></ul></ul><ul><ul><li>Diabetic Supplies </li></ul></ul><ul><ul><ul><li>Some supplies may be covered under Part D </li></ul></ul></ul><ul><ul><li>“ Welcome to Medicare” physical exam </li></ul></ul><ul><ul><li>Yearly “Wellness Exam” after 12 months on Part B </li></ul></ul><ul><ul><ul><li>Part B deductible does not apply </li></ul></ul></ul>
  10. 11. <ul><li>Part B premium for 2011 is $115.40 for those new to Medicare. </li></ul><ul><ul><li>Higher premiums for those earning more than $85,000 filing single or $170,000 filing joint with spouse </li></ul></ul><ul><ul><li>Penalties for late enrollment </li></ul></ul><ul><li>Part B deductible for 2011 is $162 </li></ul><ul><li>Part B generally pays 80% of the cost after the deductible </li></ul><ul><li>You pay the remaining 20% (co-insurance) in some instances co-pays may apply for certain services </li></ul><ul><li>There is no Out of Pocket Limit for the Part B co-insurance!!! </li></ul>
  11. 12. <ul><li>Neither Part A or Part B cover the following: </li></ul><ul><li>Acupuncture </li></ul><ul><li>Chiropractic (few exceptions) </li></ul><ul><li>Cosmetic Surgery </li></ul><ul><li>Dental Care </li></ul><ul><li>Routine Eye Exams </li></ul><ul><li>Routine Foot Care </li></ul><ul><li>Hearing Aids or Tests unless order by your doctor </li></ul><ul><li>Orthopedic Shoes </li></ul><ul><li>Service from non-Medicare Providers </li></ul><ul><li>Services incurred outside of the U.S. </li></ul>
  12. 13. <ul><li>Original Medicare </li></ul><ul><li>No Part A premium for most </li></ul><ul><li>Part B premium for all, varies for higher income </li></ul><ul><li>Deductibles apply </li></ul><ul><li>Co-pays may apply under Part A for long hospital stays </li></ul><ul><li>Co-insurance applies for Part B services </li></ul><ul><li>There is no Out of Pocket Maximum for either Parts A or B </li></ul>
  13. 14. <ul><li>Provide Supplemental coverage to Original Medicare </li></ul><ul><li>Approved by the individual states </li></ul><ul><li>Generally cover expenses that Medicare does not such as Part A & B deductible, Part B co-insurance, First 3 pints of blood, etc… </li></ul><ul><li>Usually do not go beyond what Original Medicare covers </li></ul><ul><li>Do not include Part D coverage </li></ul><ul><li>More comprehensive coverage than Part C plans but, also more expensive </li></ul><ul><li>Require Part A & B coverage </li></ul>
  14. 15. <ul><li>Part C - Medicare Advantage (MA) </li></ul><ul><ul><li>Must be enrolled in both Part A & B to participate </li></ul></ul><ul><ul><li>Coverage provided by private insurers </li></ul></ul><ul><ul><li>Medicare pays a fixed amount to the company </li></ul></ul><ul><ul><li>Plans must be filed and approved each year by CMS </li></ul></ul><ul><ul><li>Must offer benefits at least as good as Original Medicare </li></ul></ul>
  15. 16. <ul><ul><li>May offer benefits above and beyond what Medicare provides, such as dental, hearing and vision benefits </li></ul></ul><ul><ul><li>Must include an Out of Pocket Maximum </li></ul></ul><ul><ul><li>Providers bill private insurers, not Medicare </li></ul></ul><ul><ul><li>Premiums are usually lower than Medicare Supplement plans </li></ul></ul><ul><ul><li>Part B premium must still be paid </li></ul></ul><ul><ul><li>Includes HMO’s, PPO’s, PFFS, & Medicare M SA’s </li></ul></ul>
  16. 17. <ul><li>Part D - Prescription Drug Plan (PDP) </li></ul><ul><li>Provides Medicare Beneficiaries with assistance in paying prescription drug costs </li></ul><ul><ul><li>Coverage provided by private insurers </li></ul></ul><ul><ul><li>Requires minimum coverage level - “Creditable Coverage” </li></ul></ul><ul><ul><li>Beneficiary is subject to penalty if they don’t have or maintain creditable coverage </li></ul></ul><ul><ul><li>May be purchased “stand alone” </li></ul></ul><ul><ul><li>Sometimes imbedded in a Medicare Advantage Plan (MAPD) </li></ul></ul>
  17. 18. <ul><li>Formulary - list of drugs covered under the plan </li></ul><ul><li>Creditable Coverage - coverage that is at least as good as the Medicare Standard Requirement </li></ul><ul><li>Coverage Gap - prescription costs not covered by the plan (also referred to as the “Donut Hole”) </li></ul>
  18. 19. <ul><li>Drugs already covered by Medicare Part A or Part B </li></ul><ul><li>Drugs used for anorexia, weight loss, weight gain, fertility, cosmetic purposes, hair growth, or symptomatic relief of cough and cold </li></ul><ul><li>Prescription vitamins and mineral products </li></ul><ul><li>Non-prescription drugs </li></ul>
  19. 20. <ul><li>Employer Sponsored </li></ul><ul><ul><li>Voluntary Plans </li></ul></ul><ul><ul><li>Retirees from Group Coverage </li></ul></ul><ul><ul><li>Part-time employees </li></ul></ul><ul><li>Medicare Supplemental Coverage </li></ul><ul><ul><li>Flexibility in coverage choices </li></ul></ul><ul><ul><li>Optional Benefit additions </li></ul></ul><ul><li>Creditable coverage Part D options </li></ul><ul><ul><li>Includes coverage for all drugs through the “Coverage Gap” </li></ul></ul><ul><li>Available at any time during the year </li></ul>
  20. 21. <ul><li>Original Medicare only with a stand-alone Part D plan </li></ul><ul><li>Original Medicare with a Medicare Supplement Plan and a stand-alone Part D Plan </li></ul><ul><li>Medicare Advantage Plan that includes Part D coverage </li></ul><ul><li>Group Retiree Plan (if available) with a Part D plan included </li></ul>
  21. 22. <ul><li>Want to know more about the Senior Market? </li></ul><ul><li>Call us at 800-234-9488 </li></ul><ul><li> </li></ul><ul><li>We provide the path to your success! </li></ul>